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Postgrad. med. J. (September 1968) 44, 728-732. Constipation in the elderly E. GORDON WILKINS Consultant Geriatrician to the York Hospitals Causes While considering lack of essentials one should Most of the causes of constipation in younger mention lack of thyroid: constipation is usual in age groups apply to the elderly and I will not hypothyroidism which is easily missed, as a harsh attempt a systematic classification (Table 1). When voice, dry skin, cold intolerance and slow mental- bowels have not acted for some days after illness ity may all be attributed to old age. relatives will say 'But she hasn't eaten anything'- Muscular weakness is often found in the and they are right. Lack of food whether from elderly. The diaphragm is weak, hiatus hernia starvation or illness may be a cause, especially common, and chest and heart conditions may if food is easily absorbed and lacking in insoluble further make straining difficult. Weak abdominal cellulose residues or roughage. Lack of sufficient muscles, wiAth hernia at various sites often ignored fluids may also cause constipation. This may be by patient and physician, all add to the difficulty. due to sweat loss in fever or hot weather, loss It is possible that the bowel musculature itself by vomiting, or diuresis for instance in diabetes, gradually weakens with age. causing dehydration. A helpless old person can Bowel abnormalities such as carcinoma or easily become dehydrated even with ample fluid diverticulitis should be considered. on the locker, simply because nursing staff do Rectal stasis or dyschezia. Neglect of the not ensure that it is taken. Even if given fre- normal call to stool sent up to the brain when quently, much is often spilt and little swallowed. the rectum fills may be due to a variety of Sometimes the elderly, who have small capacity reasons. bladders and suffer frequency of micturition, The elderly do not rush off to school or office habitually take insufficient fluid for fear of incon- but there may be aversion to the discomfort of tinence or the need to make frequent visits to the toilet. This may involve a difficult journey, the toilet. With old kidneys passing urine of climbing stairs with laboured breathing or arth- fixed low concentration the risk of dehydration ritic joints, or negotiating in winter the icy steps is the greater. and slippery yard to the cold outside closet. It TABLE 1 is surprising how many old people endure such Some causes of constipation in the elderly conditions in old housing which would not be tolerated by the young. Fear of pain from piles Lack of physiological needsFood or fissure may add to the aversion. Cellulose residues Depression is usually associated with constipa- Fluids Thyroid tion, but I think probably the commonest cause Muscular weakness, herniae Diaphragm in the elderly of neglect of the call of the full Abdominal wall rectum is the brain dulled and damaged by Pelvic floor cerebral vascular disease. The bowel soon Bv ,vel musculature becomes lethargic and overloaded and the patient Bowel abnormalities Carcinoma ceases to be aware. Diverticulitis Neglect of call to stool Discomfort of toilet Many drugs cause constipation. Paradoxically Fear of pain-piles, fissure the first to be considered are purgatives. Bowel Vascular brain damage obsession is common as the older generation were Depression indoctrinated with the need for 'cleansing the Drugs Purgatives system'. The laxatives they often take may empty Iron the whole colon instead of only the distal portion. Codeine Antacids-calcium carbonate Physiological constipation ensues while the colon Anti-spasmodics refills, which in turn is regarded as a need for Anti-hypertensives more pills. Indeed many symptoms formerly at- Anti-Parkinsonism drugs tributed to constipation are now known to be due Barbiturates, sedatives to the purgatives taken. Constipation in the elderly 729 Among iatrogenic causes must be remembered in finding. She died of bronchopneumonia and iron, compound codeine tablets, antacids such as post mortem showed no growth anywhere. calcium carbonate and aluminium hydroxide, (2) Constipation may be associated with mental antispasmodics such as propantheline, anti- confusion and restlessness in the old person. The hypertensive drugs and ganglion blockers, drugs chronic discomfort of constipation may make for Parkinsonism such as benzhexol or benztro- her confused but unable to identify the cause, pine, and barbiturate sedatives, which for other just as a baby will cry when uncomfortable from reasons also are best avoided in the elderly. a wet nappy or projecting pin without being able to say what is wrong. Alternatively it may Syndromes be that confusion from say a minor stroke will Though constipation may occur in isolation or prevent the brain responding to the call to stool in combination with a great variety of symptoms and so initiate constipation. Which comes first certain syndromes (Table 2) occur sufficiently does not matter provided the association is recog- commonly in the elderly to justify mention. nized: improvement of mental function usually accompanies the treatment of constipation. TABLE 2 Mrs L.H. aged 88 had been forgetful for some Some syndromes of constipation in the elderly months, disturbed and noisy at nights, but able to walk and dress until a week before admission 1. Anorexia, weight loss, lassitude-? growth when she took to bed with nausea but no vomit- 2. Mental symptoms ing. Since then she had become more confused, Confusion, restlessness repeatedly getting in and out of bed, and had 3. Urinary symptoms fallen on the stairs, causing bruising but no bone Frequency, incontinence injury. On admission she was confused and rest- Infection less, climbing over the cot sides. There was no Retention with overflow significant finding except a doubtful plantar res- 4. Spurious diarrhoea, faecal incontinence ponse, but she was very constipated. This was 5. Intestinal obstruction treated during the next few weeks and her mental state gradually improved, though there were relapses, one being associated with a chest infec- (1) The patient presents with anorexia, weight tion. However she eventually became able to loss and lassitude, symptoms which give rise to walk, dress and attend to her own toilet, and for the suspicion of a growth. Barium meal will ex- the last 4 months has lived a normal social life clude carcinoma of the stomach. Barium enema in our convalescent hospital, helping other patients is often unsatisfactory as ordinary preparation by doing little jobs for them. Her niece, remem- fails to clear the loaded bowel, but if this even- bering her former confusion and restlessness, tually excludes colon pathology the incidental refused to have her back so she has now to correction of constipation may result in improve- await a place in a Welfare Home. ment. However, this does not always happen. (3) Constipation may present entirely with Mrs K.C. aged 70 gave a history of a stroke urinary symptoms. There may be frequency of 15 months before with two more recent recur- micturition, incontinence and urinary infection rences and she had been bedfast at home for 6 for which antibiotic treatment will fail unless the weeks. I was called to see her for an attack of constipation is also treated. Or there may be vomiting with constipation for a week and in- retention with overflow dribbling incontinence, continence. She was admitted with a view to re- commonly due to faecal impaction. habilitation and regulation of bowels. She (4) Spurious diarrhoea from faecal impaction improved for a time and was able partially to is well known in geriatrics but the inexperienced dress herself and walk with a frame. However nurse is often misled. It is reported that the her appetite was poor and she persistently lost patient is dirty and constantly soiling with faeces. weight. Chest X-ray showed nothing significant When I feel the faecal masses I insist on the and barium meal was also negative. Constipation nurse also putting on a glove and feeling them, remained as shown by palpable scybala in colon and she marvels to find the patient constipated and rectum. This was treated with some success, with liquid faeces escaping around the irritating but her general condition continued to deterior- scybala. Sometimes a single faecal mass forms a ate. Nortryptiline was given as she was thought ball-valve obstruction which a patient of mine to be depressed. She lost over 20 lb (9 kg) in diagnosed herself. She was a very interesting case. weight in 2 months and we thought she must have Mrs MS. aged 83, living alone, was admitted a growth somewhere which we had not succeeded one cold January day with accidental hypo- 730 E. Gordon Wilkins thermia and a temperature of 87°F. She gradu- and gave a history of anorexia, weakness and ally improved but when a month later she was constipation similar to the first syndrome des- almost ready to return home she suddenly cribed earlier. Six weeks before admission she developed acute rheumatoid arthritis of hands had a fall and went to her daughter's where she with anaemia, raised ESR and strongly positive continued weak and ill with vomiting and diar- latex test. As this subsided she was depressed and rhoea. On admission she was dehydrated and preoccupied with her bowels, complaining that emaciated with anaemia, skin pigmentation, glos- something came down and caused a stoppage. sitis and angular stomatitis. There were no clinical How right she was, for a ball-valve of solid signs of carcinoma. The bladder was full and the faeces was doing just that! I broke it up and rectum plugged with a mass of solid faeces, so evacuated it, but a fortnight later Sister had to the diarrhoea had been spurious. She was given do the same again and in spite of treatment, fluids, complan, iron and vitamins and the bowels twice more in the next month. She became more were treated with Senokot by mouth and Dulco- anaemic in spite of iron, occult blood tests were lax suppositories. After temporary improvement positive and a barium enema then showed an she gradually deteriorated to her death. Unfor- annular carcinoma of the descending colon just tunately permission for post mortem was refused. distal to the splenic flexure. This was removed I postulate that when living alone she began by Mr Matheson with end-to-end anastomosis. to get constipated, her appetite declined and she A saccular aneurysm of the abdominal aorta, did not get herself proper meals. Her daughter noted clinically, was confirmed at operation. She said that in all the 6 weeks she was with her did well and went for convalescence but there she did not have her bowels moved properly, had a stroke with left hemiplegia. She made re- merely passing small quantities of liquid motion. markable recoveries from this and a recurrence Further anorexia and vomiting perpetuated a 6 weeks later, but succumbed 2 months after vicious circle of malnutrition. that to bronchopneumonia. Post mortem showed Similarly on the mental side confusion, cerebral the colon cancer completely cured but the path- vascular disease or depression may lead to neglect ologist added 'there is evidence of constipation'. of the call to stool and constipation. Chronic Let us not imagine constipation is easily treated! discomfort from this may aggravate the confu- (5) Finally there are the cases sent in as acute sion, or pain from the fissure or piles may cause intestinal obstruction, and sometimes even opened fear, and both may lead to further neglect of up by the surgeon. going to the toilet. Or there may be a crossover, as in the first case described (Mrs K.C.), arterio- Vicious circles sclerotic dementia and depression causing con- From the foregoing it may be seen that vicious stipation leading to anorexia and weight loss with circles (Fig. 1) may be set up both on the physical suspicion of growth. and mental side. Physically any debilitating ill- ness may render the old person weak and often Treatment bedfast and constipated. Appetite is lost, resulting The advantages of getting the elderly patient in further wasting, malnutrition and weakness. I up, out of bed and active are many, but not think this occurred in the following case: least among them is management of the bowels Mrs H.A.S. aged 85 had been living alone (Table 3). It is essential for the toilet to be near, warm, comfortable, of suitable height, and with Physical Mental hand grips. Unlike younger age groups the Illness Vascular brain damage elderly are not usually short of time. Confinement to bed Depression Weakness Neglect ot cal to stool TABLE 3 Management of constipation in the elderly The toilet Nearness, warmth, comfort, height, hand-grips Constipation Malnutrition with Confusion, fear Diet Fruit, vegetables, fluids loaded By mouth Lubricants rectum. Bulk producers Stool softeners Anorex ia Overf low Discomfaor Laxative drugs with pain (fissure, piles) Per rectum Digital examination spurious Suppositories diarrhoea Small enemas FIG. 1. Vicious circles of constipation in the elderly. (Large enemas) Constipation in the elderly 731 The importance of diet was brought home to duced. However, I am afraid the practice of giv- me by a paraplegic patient of mine. ing them intermittently in purgative doses still Miss E.H. is now aged 62 and has been goes on. paralysed and anaesthetic from the groins down Of all the agents used from below I would put for 30 years from a pathology never established first the exploring finger. There are well known at the time, but there was a previous history of aphorisms stressing the importance of the rectal tuberculosis. Fortunately for her the sacral nerves examination. The presence of faeces in the supplying bladder and rectum escaped so she rectum of a patient unaware of the fact is diag- retained control. She was, however, very constip- nostic of constipation, and the consistence- ated, with bowels that could only be persuaded whether hard or soft-gives us further informa- to act with difficulty with regular aperients. She tion. Digital evacuation of a loaded rectum results developed a resistant anaemia which was found in surprise, relief and gratitude from patient and to be due to chronic renal disease. Blood urea in relatives, but this is only a beginning. Nursing June 1966 mounted to 480 mg and she was put staff who traditionally preside over the patient's on treatment which included a Giovanetti diet bowels should be taught the technique of painless containing much fruit and vegetable. From then rectal examination-pressing backwards with the on bowels acted daily and were no problem. flat of the well lubricated finger before inserting Latestest blood urea incidentally is 38 mg but the tip inwards-so that progress of treatment anaemia persists. can be regularly checked. I recently discovered Specific measures divide themselves into those faecal retention with overflow in a patient in one given from above and those from below. There of my wards. In spite of my instructions treat- are various categories of substances given by ment was not given daily and progress was not mouth. Of lubricanta liquid paraffin is typical, checked. I found the condition unchanged a fort- but disadvantages of long-term usage are well night later and had to do a digital evacuation. known; lymphatic blockage, interference with Enemas are not used routinely in our wards. The absorption of fats and fat-soluble vitamins, and small Fletcher's enema has its advocates, and the discomfort of anal seepage. some use warm olive oil or glycerine. In general Bulk producers whether from Psyllium seeds they have been, replaced by suppositories and or Sterculia, such as Normacol, or cellulose we prefer the bisacodyl (Dulcolax) suppository. derivatives such as methyl cellulose (Celevac) or Staff should be instructed not to push it into hydroxyethyl cellulose (Prepacol) have their uses the faecal mass but to insert it in contact with in colostomy management or preparation for X- the rectal mucosa so that absorption can take rays, but when the aged bowel has already place. Some like a glycerine suppository, or a become insensitive the further bulk seems only moistened Beogex suppository which produces to add to faecal distension. However they have a carbon dioxide with explosive effect. place in treatment. Our routine is either Senokot, Dulcolax or Stool softeners or wetting agents are useful in Dorbanex at night followed by a Dulcolax sup- breaking up faecal masses in chronic constipa- pository in the morning until regularity is tion. Dioctyl sodium sulphosuccinate is the agent achieved, attention being paid, of course, to diet in Dioctyl Medo and Norval, poloxalkol in and fluids. Dorbanex. These are usefully combined with the I would stress in conclusion that the treatment anthracene laxative danthrone in Normax and of established constipation in the elderly requires Dorbanex. The former is only in capsules but if a course of daily treatment and is not just a these are found difficult to swallow liquid matter of an occasional aperient or enema from Dorbanex is useful. the District Nurse. With faecal incontinence it I will not attempt to describe all the various is worth much effort to make the patient socially drugs that have been used to treat constipation. acceptable again by re-educating the bowel to Gone are the days of castor oil or rounds with function at convenient times. It may take weeks large bottles of black and white mixtures. The rather than days of regular treatment and super- only two laxatives we use in our Geriatric Unit vision and even then one may not be successful are Senokot, the well known standardized senna as the following case shows: preparation, and bisacodyl (Dulcolax). Both are Mrs L.K. a woman of 82 had taken to bed a thought to act after absorbtion by stimulation of month before admission complaining of pain in Auerbach's plexus in the large intestine, and the back and legs and inability to stand. She was both are useful. They are best given regularly cared for by an 89-year-old husband who found daily, the dose being gradually increased until the it difficult to help her to the commode. She was desired effect is obtained and then gradually re- thin, weak and anaemic with low blood pressure 732 E. Gordon Wilkins and oedema of the feet. Faecal masses were felt large mass of presumed faeces in the descending per abdomen and per rectum and there was a colon with a distended bladder needing a catheter, sacral pressure sore. Haemoglobin was 90 g the and a rectum overflowing with spurious diar- blood film showing both macrocytosis and iron rhoea. Several attempts were made at digital deficiency change. There were no neurological evacuation and Dulcolax suppositories were con- signs of sub-acute combined degeneration. tinued. She lingered on in a pathetic state and Lumbar X-ray showed osteoporosis and osteo- died 6 weeks after admission. Post mortem arthiritis. She was given Neo-Cytamen 1000 ,ug showed as expected widespread bronchopneu- daily for 5 days, Fersemal, Senokot at nights and Dulcolax suppositories in the mornings. Though monia. The upper alimentary tract was normal. there was a reticulocyte response of 12% the The descending and sigmoid colon and rectum haemoglobin went down to 80g and she devel- were enormously dilated by impacted faeces, the oped a chest infection treated first with a course total mass like a rugby football measuring 12x of tetracycline. When sputum grew penicillin 9f in (30 x 24 cm). There was no organic cause sensitive Staph. pyogenes she was given penicil- of obstruction. Pressure of the faecal mass had lin. Meanwhile her general condition deteriorated caused bilateral hydronephrosis. Our treatment and her pressure sore was worse. There was a of constipation had to admit defeat!
"Constipation in the elderly"